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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191605144
Report Date: 08/02/2024
Date Signed: 08/02/2024 03:37:57 PM

Document Has Been Signed on 08/02/2024 03:37 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK SW RO, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME:BETHANY PRE-SCHOOLFACILITY NUMBER:
191605144
ADMINISTRATOR/
DIRECTOR:		TONIA HILLFACILITY TYPE:
850
ADDRESS:2244 CLARK AVENUETELEPHONE:
(562) 985-0714
CITY:LONG BEACHSTATE: CAZIP CODE:
90815
CAPACITY: 107TOTAL ENROLLED CHILDREN: 117CENSUS: 75DATE:
08/02/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:30 PM
MET WITH: Assistant Director/ Natalie RobideauxTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Ashley Calderon conducted a Case Management - Other. LPA met with Assistant Director Natalie Robideaux. LPA was at the facility conducting a complaint investigation.

On 5/17/24, LPA requested child file for Child #1 (C1), LPA was only provided with C1’s admission agreement enrollment form. During interview with staff, Teacher #1 and Director Gina Martinez informed LPA Calderon that Child #1 (C1) parent did not provide proper documentation for child upon enrollment. Due to lack of documentation's, there was a discrepancy/ issue regarding snacks to provide to C1. Director Ms. Martinez informed LPA that C1 parent only submitted admission agreement enrollment form.

Upon review of the Parent/Student Handbook Page.17 states all forms required to submit to the facility. Page 17, states forms are to be on file one week prior to beginning of the school and if mentioned forms are not on file one week prior, child will no able to attend.

Based on record review C1 attended school without completion of all forms required from school and by licensing child record requirements. Therefore, Child’s records were found to be incomplete.

The following deficiencies listed on the attached LIC 809-D (deficiency page) are being cited in accordance with California Code of Regulations Title 22, Division 12, Chapter 1 and Section CCR & H&S.

A notice of site visit was given and must remain posted for 30 days. Failure to maintain posting as required, will result in an immediate $100 civil penalty. Appeal Rights were given alongside with report. Exit interview was conducted with Director GIna Matiinez and Natalie Robideaux
SUPERVISORS NAME: Valarie Cook
LICENSING EVALUATOR NAME: Ashley Calderon
LICENSING EVALUATOR SIGNATURE: DATE: 08/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/02/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/02/2024 03:37 PM - It Cannot Be Edited


Created By: Ashley Calderon On 08/02/2024 at 02:00 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: BETHANY PRE-SCHOOL
FACILITY NUMBER: 191605144

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/02/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/09/2024
Section Cited
CCR
101621

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Child Records
(a) In addition to Section 101221, the following shall apply: (b)Ea. child's record shall include...(1)written medical assessment...(6)Health clearances(8) Information...
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Child #1 is no longer enrolled in the facility. LPA provided Title 22 Regulation on Child's Records. LPA will request Administration to review and sign the Regulation document provided and an office staff will send LPA Calderon via email POC by POC due date.
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regarding any allergies the child may have.

This requirement was no met as evidenced by: Child #1 only had Admission Enrollment Agreement form in child's file. Facility was unable to provide completed C1 child record/file.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Valarie Cook
LICENSING EVALUATOR NAME:Ashley Calderon
LICENSING EVALUATOR SIGNATURE:
DATE: 08/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/02/2024


LIC809 (FAS) - (06/04)
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